ShiftMed - Missed Punch Form

Missed Punch Form

As an employee of ShiftMed, please fill out this form only if you have worked a shift that requires adjustment. Please note, since this is a manual submission, there will be a longer processing time than typical payroll. For more details, see our Help Center here: https://help.shiftmed.com/en/articles/5492131-issues-with-clocking-in-and-out
Please Select the Type of Form (what type of Facility?):*
Name*

First NameLast Name
Your Phone Number*
Facility Name*
**Please only select a facility name from the dropdown**
Facility Name*
Please select one
Genesis Facility*
California Facility*
Date of Shift*

MonthDayYear
Clock In Time*

Hour Minutes

AM/PM Option
Break

Hour Minutes

AM/PM Option
Break Duration
Clock Out Time*

Hour Minutes

AM/PM Option
Meal Break 1 Taken*

YesNo
Meal Break 1 Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Meal Break 1 Waiver

Yes, the facility and I have mutually agreed to waive this meal break
Meal Break 2 Taken*

YesNo
Meal Break 2 Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Meal Break 2 Waiver

Yes, the facility and I have mutually agreed to waive this meal break
Guaranteed Shift*

YESNO
Reason for missed punch*
Detailed Reason for Missed Punch*
File Upload - Make sure to submit a Genesis-Specific Form (can be found at the facility) and you must turn in this form to the facility scheduling team so it can be approved and adjusted*

Cancelof
Should be Empty: